General Practice Setting Research Articles

Recognizing elderly women with sleep problems and falls from information on comorbidites and medications in a continuous use

Geriatric syndromes represent new, comprehensive concepts, which can help identifying vulnerable elderly people with multimorbidity. There is also a problem in using the result in a general practice working environment. We suggest fast audit as a method for conducting research on a small scale. The aim of this study was to find out the specific characteristics that can be used for a fast recognition of elderly women who have sleep problems and are susceptible to falls. We conducted a survey on a sample of 105 elderly women (age range 60-80 years, average 68.7±5.1 SD), in a general practice setting, in the town of Osijek, eastern Croatia. The sleep disturbance was identified using the standard Pittsburgh Sleep Quality Index, while information on falls were taken from electronic health records (eHRs) and patient interviews. We used a multi-item questionnaire for socio-demographic characteristics and lifestyle habits. EHRs were used to diagnose problems associated with sleep disturbances and falls, as well as for the use of medication that affect mental functions. We found out that 74.2% of examined women had sleep problems, and 25.7% of them experienced falls in the past two years. Diagnoses that distinguished women with and those without sleep problems included dyspepsia and urinary tract infections (50% vs. 23.1%). Women with sleep problems, compared to those without them, more commonly used two or more medications, usually antidepressants, analgesics and anxiolytics. Lower back pain and osteoporosis were used as screening tools for women susceptible to falls, compared to women without reports of falling. (81.5% vs 61.5% and 22.2% vs. 5.1%). Women with falls had a higher degree of overlapping with sleep disorders (81.5%). Anxiolytics application could be a link between sleep disorders and falls (the overlapping ratio 68%).

The Multidimensional Prognostic Index in general practice: One-year follow-up study.

Older patients' health problems in general practice (GP) can often not be assigned to a specific disease, requiring a paradigm shift to goal-oriented, personalised care for clinical decision making. To investigate the predictive value of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI) in a GP setting with respect to the main healthcare indicators during the 12months following initial evaluation. One hundred twenty-five consecutive patients aged 70years and older were enrolled in a GP and followed up to one year. All patients underwent a CGA based on which the MPI was calculated and subdivided into three risk groups (MPI-1, 0-0.33=low risk, MPI-2, 0.34-0.66=moderate risk and MPI-3, 0.67-1, severe risk). Grade of Care (GC), hospitalization rate, mortality, nursing home admission, use of home care services, falls, number of general practitioner contacts (GPC), of geriatric resources (GR) and geriatric syndromes (GS) during the 12 months following initial evaluation were collected. The MPI was significantly associated with number of GS (P<.001), GR (P<.001), GC (P<.001) as well as with the average number of GPC per year (mean 10.4, P=.046). Interestingly, the clinical judgement of the general practitioner, in this case knowing his patients for 16 years on average, was associated with adverse outcomes to a similar extent than the prediction offered by the MPI (GP/adverse outcomes and MPI/adverse outcomes P < .001). The MPI is strongly associated with adverse outcomes in older GP patients and strongly predicts the number of GPC up to one year after initial evaluation. Considering the feasibility and the strong clinimetric properties of the MPI, its collection should be encouraged as early as possible to disclose risk conditions, implement tailored preventive strategies and improve cost-effectiveness of healthcare resources use.

The use of direct resin composite restorations in the management of localized anterior tooth wear: A clinical update part 1

The aim of this article is to provide the reader with the necessary information to manage localized anterior tooth wear cases successfully using minimally invasive and conservative methods in a general dental practice setting. This article will focus on the use of direct resin composite restorations. It will provide an update on the different techniques available to restore anterior tooth wear using direct resin composite and its method of application. CPD/Clinical Relevance: Numerous epidemiological studies have reported tooth wear to be increasing in incidence amongst the general population. This article aims to describe a methodical conservative approach for the management of worn teeth.

Surgical management of acute lacerations.

Acute lacerations are a common occurrence in everyday life that can, in most cases, be well managed in the primary care setting. The aim of this article is to describe the principles of surgical repair techniques for simple linear lacerations. Wound defects that require flaps or skin grafts necessitate an additional skill set beyond the scope of this article. With prior basic training in performing instrument ties, additional information regarding suture technique,selection and aftercare enable the surgical repair of simple acute lacerations in the general practice setting.

\u201cStrong Teeth\u201d\u2014a study protocol for an early-phase feasibility trial of a complex oral health intervention delivered by dental teams to parents of young children

BackgroundDental attendance provides an important opportunity for dental teams to explore with parents the oral health behaviours they undertake for their young children (0–5 years old). For these discussions to be effective, dental professionals need to be skilled in behaviour change conversations. The current evidence suggests that dental teams need further support, training and resources in this area. Therefore, the University of Leeds and Oral-B (Procter & Gamble Company) have worked with the local community and dental professionals to co-develop “Strong Teeth” (an oral health intervention), which is delivered in a general dental practice setting by the whole dental team. The protocol for this early phase study will explore the feasibility and acceptability of the Strong Teeth intervention to parents and the dental team, as well as explore short-term changes in oral health behaviour.MethodsForty parents (20 of children aged 0–2 years old, and 20 of children aged 3–5 years old) who are about to attend the dentist for their child’s regular dental check-up will be recruited to the study. Parents and children will be recruited from 4 to 8 different dental practices. In the home setting, consent and baseline oral health behaviour data will be collected. The researchers will ask parents questions about their child’s oral health behaviours, including toothbrushing and diet. Three different proxy objective measures of toothbrushing will be collected and compared with self-report measures of parental supervised toothbrushing (PSB).DiscussionThe parent and child will then attend their dental visit and receive the Strong Teeth intervention, delivered by the dental team. This intervention should take 5–15 min to be delivered, in addition to the routine dental check-up. Furthermore, children aged 0–2 years old will receive an Oral-B manual children’s toothbrush, and children aged 3–5 years old will receive an Oral-B electric rechargeable children’s toothbrush. At 2 weeks and 2–3 months following the Strong Teeth intervention, further self-report and objective measures will be collected in the parent/child’s home. This data will be supplemented with purposively sampled qualitative interviews with parents (approximately 3 months following the intervention) and dental team members (following delivery of the intervention).Trial registrationISRCTN Register, (ISRCTN10709150)

Validity of microscopy for diagnosing urinary tract infection in general practice – a systematic review

Objective: To investigate the validity of microscopy as a diagnostic tool for urinary tract infection in general practice.Methods: (Design/setting) A systematic review was conducted by searching Medline for clinical studies made in general practice, outpatient clinics or similar settings in which the accuracy/validity of microscopy was evaluated with urine culture as the reference standard.Results: Our search resulted in 108 titles. 28 potentially eligible studies were retrieved for full-text reading. We included eight studies involving 4582 patients in this review. The quality of the studies was moderate to high. Specificity ranged from 27% to 100%, sensitivity from 47% to 97%. The variation between studies did not allow for meta-analysis.Conclusion: We did not find substantial evidence to determine the clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI.Key pointsUrinary tract infection is common in general practice. Methods for precise diagnosis are needed in order to avoid inappropriate treatment. Currently no evidence-based consensus exists regarding the use of urinary microscopy in general practice.We did not find substantial evidence to determine the overall clinical validity of microscopy performed in general practice on urine samples from patients with symptoms of UTI.Light microscopy with oil immersion had high sensitivity and specificity but is time-consuming. Phase-contrast microscopy is quick and had high specificity but lower sensitivity.

Investigating the role of practice nurses in the early identification and management of chronic kidney disease in the general practice setting: An integrative review

Aim The aim of this study was to critically review research literature investigating the role of practice nurses in the early identification and management of chronic kidney disease (CKD) in the general practice setting. Method An integrative review was performed to determine the extent to which the topic has been investigated. Quantitative and qualitative research papers were systematically located in peer-reviewed journals in electronic databases. Included papers were critically appraised using the relevant CASP appraisal tools. Findings There is a paucity of research investigating the role of practice nurses in the early identification and management of CKD in primary health care. Three articles published between 2013 and 2017 were identified: two quantitative studies and one qualitative study. One study from The Netherlands quantified positive outcomes of practice nurse-centred management of CKD in general practice. Conclusion Practice nurses may be effective in the early identification and management of CKD, including improving blood pressure control. Providing education to practice nurses appears to be a key factor in increasing practice nurses’ involvement in identification and management of CKD. Further research is warranted to see if the results are transferable to other jurisdictions.

Poor prognosis of child and adolescent musculoskeletal pain: a systematic literature review

ObjectivesTo identify baseline patient characteristics that are (1) associated with a poor outcome on follow-up regardless of which treatment was provided (prognosis) or (2) associated with a successful outcome to...

Glycaemic control of Type 2 diabetes in older patients visiting general practitioners: An examination of electronic medical records to identify risk factors for poor control

ObjectiveTo investigate factors associated with glycaemic control of diabetes in older patients in the general practice setting in metropolitan Melbourne, Australia. MethodThis retrospective study used the data from 10,257 patients aged ≥ 65 years with Type 2 diabetes from the Melbourne East Monash General Practice Database (MAGNET), 2009–2014. Poor glycaemic control was defined as HbA1c ≥ 9.0%. Univariate and multivariate analyses were conducted to assess the association between risk factors and glycaemic control. ResultsOf the total 10,257 patients, 6819 (66.5%) had their HbA1c recorded within a period of 2 years prior to their last GP visit. Between 4% and 6% had HbA1c level ≥ 9.0%. Robust predictors of poor glycaemic control were found to be decreasing age group (OR = 0.77, 95% CI: 0.65–0.90) and prescribed insulin (OR = 2.83, 95% CI: 2.41–3.32). ConclusionOne third of older patients with Type 2 diabetes did not have HbA1c recorded in the previous 2 years, despite clinical guidelines recommending at least annual testing. Many older patients had good glycaemic control, however the findings indicate that those aged 65–74 and those prescribed insulin may require special care and management to achieve this.

University of Limerick — Graduate Entry Medical School, General Practice Quality Assurance Initiative

BackgroundAt 18 weeks duration, University of Limerick — Graduate Entry Medical School (UL–GEMS) has the longest general practice clinical attachment for medical students in Ireland and fulfils the educational criteria for a Longitudinal Integrated Clerkship (LIC).The longer the clinical placement the greater the imperative to see that these practices achieve satisfactory educational standards.AimThis project describes a quality assurance initiative of general practices that participate in the education of medical students at GEMS.MethodA literature review of previous quality assurance initiatives in relation to general practices that teach medical students was performed. Information gained from this process was then compared with UL-GEMS own criteria for teaching general practices. A set of criteria by for assessing teaching general practices was devised. The assessment process included a combination of self-assessment by the GP tutors and practice visits by the UL-GEMS teaching staff.ResultsNearly 100% of teaching practices had the correct teaching facilities, such as own room for the student or own computer. Suggested teaching methods, such as parallel consulting, as advised by the Department of General Practice were carried by 100% of practices. Use of the two-way feedback form and the GP/Student manual was poor. GP tutors requested more regular visits form the GP teaching staff as well as more guidance on content for formal tutorials so that a consistency teaching approach could be achieved.ConclusionThis was the first quality assurance initiative on an extended clinical placement. The knowledge gained will lead to a more inclusive standard setting process for teaching medical students in general practice settings.

Antibiotic prescribing for tonsillopharyngitis in a general practice setting: Can the use of Modified Centor Criteria reduce antibiotic prescribing?

Empirical treatment of sore throat with antibiotics has historically been aimed at preventing complications of group A β-haemolytic streptococcus infection. Threats posed by multi-resistant organisms mean that antimicrobial stewardship is important. The aim of this study was to investigate antibiotic prescribing for tonsillopharyngitis in relation to components of the Modified Centor Criteria (MCC) documented in consultation records. Analysis of two rural Australian general practices was performed using clinic management software. A keyword search for 'tonsillopharyngitis/tonsillitis/pharyngitis' identified consultations. Antibiotic prescribing was frequent and congruent with existing studies; however, documented evidence of history and examination covering MCC components was associated with lower antibiotic prescribing (77.7% versus 85.5%, P <0.001; odds ratio: 2.4; 95% confidence interval: 1.8, 3.3, P <0.0001). We believe this is the first study that assesses the correlation between documentation and prescribing. Adopting and documenting MCC may improve appropriate prescription and patient safety and significantly reduce antibiotic prescription rates.

A focused mapping review and synthesis of a priori risk factors associated with medical misconduct

BackgroundMedical misconduct is an international problem. It is judged according to whether a doctor has endangered the health of the public. Little is known about the risk factors associated with...

A Smart Phone Based Handheld Wireless Spirometer with Functions and Precision Comparable to Laboratory Spirometers.

We report a smart phone based handheld wireless spirometer which uses a Lilly type sensing flowhead for respiratory signal acquisition and transmits the data to smartphone or other mobile terminals with Bluetooth signal transmission for data processing and result display. The developed spirometer was demonstrated to be able to detect flow rates ranging from 0–15 L/s with an accuracy of 4 mL/s, and can perform tests of flow volume (FV), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), peak expiratory flow (PEF), etc. By having the functions and precision comparable to laboratory spirometers, it satisfies the American Thoracic Society and European Respiratory Society (ATS/ERS) proposed performance requirements for spirometer. At the same time, it is low cost, light and handy, low power consumption battery-powered. The test of 12 cases of subjects using the developed spirometer also indicated that it was easy to use for both providers and patients, and suitable for the Point of Care Test (POCT) of chronic obstructive pulmonary disease (COPD) and asthma at general-practice settings and homes.

Opportunities to develop a research interest in general practice

Research delivery in general practice usually involves practices finding and recruiting patients eligible to enter research studies relevant to their care and treatment. The National Institute for Health and Research (NIHR)’s Clinical Research Network supports many practices across England to enable GPs and their staff to recruit patients into high-quality research studies on the NIHR portfolio. Involvement provides an additional source of income for the practice, but the main benefits are in staff development, quality improvement, and the ability to offer patients opportunities to contribute to important research activity. Individual GP involvement provides satisfying exposure to academic activity, which can contribute to a portfolio career or stimulate further learning or development in research activity. This article provides an overview of research delivery in the general practice setting, including resources available, consideration of the practicalities and examples of studies offered.

Opportunities for collaboration between pharmacists and clinical pharmacologists to support medicines optimisation in the UK.

Medicines optimisation is a clinician-driven, person-centred ongoing process. Pharmacists and clinical pharmacologists have medicines-related expertise to deliver medication review which optimises clinical and cost-effective use of medication, aligned with patient preferences, contributing to improved health outcomes. There is a large pharmacy workforce, directly accessible to patients, who can provide expert medicines-related care on the high street, and increasingly in general practice and care homes settings. There are a small number of clinical pharmacologists in practice, mainly working in a hospital setting. Potential opportunities for collaboration are extensive, including local initiatives in collaborative education, formulary/medicines management, electronic prescribing, service evaluation, research, direct clinical services as well as strategic planning through the Regional Medicines Optimisation Committees. Pharmacists and clinical pharmacologists have complementary skill sets and through acknowledging the differences in their approaches and valuing their unique skills, health services can ensure that patients are signposted to appropriate services.

The CKD-DETECT study: An RCT aimed at improving intention to initiate a kidney health check in Australian practice nurses.

The burden of Chronic Kidney Disease (CKD) on the Australian health system is growing. Efforts to reverse this trend have not been successful. This paper evaluates the effectiveness of a targeted asynchronous web based e-learning module on general practice nurses' behavioural intentions in relation to opportunistic screening practices for people at risk of CKD. Double blinded pre-post interventional randomised control design. Participants were nurses working in general practice settings in Australia. Participants were randomised to a knowledge based active control or targeted behavioural based intervention which were delivered using asynchronous e-learning modules. The intervention was designed to influence the behavioural constructs of the theory of planned behaviour (TPB): attitude, subjective norm and perceived behavioural control (PBC). Of the 420 participants, we analysed the primary and secondary outcomes for 212 (50.47%) who had complete follow up data. There were no significant differences (p 0.424, [d] 0.04) in behavioural intention between the intervention and control groups at follow-up, when controlling for baseline values. However, regression models assessing the relationship between the change in the TPB constructs and behavioural intention at follow-up for all participants, regardless of study arm, demonstrated a significant change in intention to initiate a kidney health check. Although these changes could not be attributed to the effect of the intervention. Attitude (r2 = 0.3525, p 0.0004) and PBC (r2 = 0.3510, p 0.0005) models accounted for approximately 35% of the explained variance in behavioural intentions and social norm (r2 = 0.3297, p 0.0171) accounted for approximately 33% of the variance. When all TPB constructs were included in the model, 37% of the variance in intention was explained. A targeted behavioural online intervention was no more effective than a knowledge based online program to improve primary health care nurses' intention to initiate a kidney health check in people at risk of chronic kidney disease. Collaborative efforts are required by all staff working in general practice to develop models of care to improve screening practices for chronic kidney disease. Future research should focus on interventions that improve collaboration between health care professionals in the primary care setting and public health campaigns to increase awareness of risks of CKD and the importance of screening in the primary care setting.

Factors associated with recruitment to randomised controlled trials in general practice: protocol for a systematic review

BackgroundRandomised controlled trials (RCTs) are frequently unable to recruit sufficient numbers of participants. This affects the trial’s ability to answer the proposed research question, wastes resources and can be unethical. RCTs within a general practice setting are increasingly common and similarly face recruitment challenges. The aim of the proposed review is to identify factors that are associated with recruitment rates to RCTs in a general practice setting. These results will be used in further research to predict recruitment to RCTs.Methods/designThe electronic databases Medline, EMBASE, Cochrane Database of Systematic Reviews, NTIS and OpenGrey will be searched for relevant articles with no limit on the date of publication. BMC Trials will be manually searched for the past 5 years. Both quantitative and qualitative studies will be included if they have studied recruitment within a general practice RCT. Only English language publications will be included. Screening, quality assessment and data extraction will be conducted by two review authors not blinded to study characteristics. Disagreement will be resolved by discussion and the involvement of a third review author if required. A narrative synthesis of the studies included will be performed.DiscussionThe review will, for the first time, systematically synthesise existing research on factors associated with recruitment rates to RCTs in general practice. By identifying research gaps to be prioritised in further research, it will be of interest to academics. It will also be of value to clinical trialists who are involved in the complex task of improving trial recruitment. Our team will use the findings to inform a prediction model of trial recruitment using machine learning.Systematic review registrationPROSPERO, CRD42018100695. Registered on 03 July 2018.

The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers.

An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians. Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics. We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women. Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

A sense of dread: affect and risk perception in people with schizophrenia during an influenza pandemic.

To explore the role of affect in risk perception and intention to adopt protective measures against pandemic swine influenza in people with schizophrenia. A cross-sectional study was conducted exploring the responses of 71 adults with schizophrenia and 238 adults attending general practice settings without schizophrenia. Participants completed a questionnaire that included items relating to: self-predicted affect (affective forecast) were they to contract swine influenza; perceived risk from swine influenza; and willingness to adopt protective measures against swine influenza. The 10-item Kessler Psychological Distress Scale (K10) and a single-item Self-Rated Health Question (SRHQ) were also included as measures. In people with schizophrenia, higher levels of predicted fear were associated with increased likelihood of perceived substantive risk from swine influenza and self-reported willingness to adopt protective measures against it. However, higher K10 anxiety subscale scores, reflecting greater concurrent anxiety, were associated with reduced likelihood of perceived substantive risk from swine influenza in people with schizophrenia. Affect appears to play a role in risk perception of influenza and willingness to take protective measures against it in people with schizophrenia.

The French version of the HSCL-25 has now been validated for use in primary care.

BackgroundThe Hopkins Symptom Checklist in 25 items (HSCL-25) helps to assess anxiety and depression in Primary Care. Anxiety and depression show considerable overlap in primary care. This self-administrated questionnaire is valid, reliable and ergonomic in the original US version. We have translated it into French. The aim of this study was to estimate the test characteristics of the HSCL-25, in its French version (F-HSCL-25), by comparing it to the Present State Examination-9 French version (F-PSE-9) and by determining its internal validity and dimensions.MethodOutpatients from three French General Practice settings (rural, semi-rural and urban) were recruited: approximately 20,000 outpatients among 17 GPs. Two groups were formed: F-HSCL-25 ≥1.75 and F-HSCL-25 <1.75. A validated cut-off score of > 1.75 was considered to indicate a clinically relevant level of symptoms of depression and anxiety. In order to obtain two balanced groups, a different method of randomization was chosen for each group. The F-PSE-9 was randomly administered to 1 in 2 patients in the F-HSCL-25 ≥1.75 group, and to 1 in 16 in the (much larger) F-HSCL-25 <1.75 group. The diagnostic performance was assessed and the test results obtained from both groups were compared with their F-PSE-9 results.ResultsOf the 1126 patients who completed the F-HCL-25, 886 joined the F-HSCL-25 <1.75 group and 240 the F-HSCL-25 ≥1.75 group. The overall prevalence of depression, using the F-HSCL-25, was 21% in these medical practices. The diagnostic performance of the F-HSCL-25 versus the F-PSE-9, the external criteria were as follows: Positive Predictive Value (PPV) 69.8%, Negative Predictive Value (NPV) 87%; Sensitivity 59.1%, and Specificity 91.4%. The Principal Component Analysis showed that F-HSCL-25 is a one-dimensional tool (anxiety and depression dimensions combined) with a Cronbach Alpha of 0.93.ConclusionThe F-HSCL-25 is an appropriate diagnostic tool for anxiety and depression in primary care in France due to its high specificity and high NPV. The HSCL-25 scale has a high eigenvalue. This pilot study will be extended throughout Europe; however, preliminary evidence suggests that the HSCL-25 is a reliable and suitable diagnostic tool for primary care.